Outwitting Cancer

The Ethics of Oncofertility Treatments

Recently I was asked to serve on an advisory committee of a research group developing new techniques to preserve fertility for cancer patients. The research is cutting-edge, scientifically elegant, and enormously promising. It is also likely to be controversial. And so before it moves from the laboratory to the clinic, we ought to think carefully about its moral implications. Catholic teaching has something useful to say about this research. But the treatments involved are complicated, and Catholic moral teaching on the subject of conception isn’t the simplest either. What happens when the two collide requires a bit of explication.

The techniques I wish to discuss arise from an emerging medical field sometimes referred to as “oncofertility.” This interdisciplinary field has developed in response to the growing success of treatment regimens for childhood cancers. Where a diagnosis of cancer for a child was once tantamount to a death sentence, there now exist very good treatment options for most childhood cancers. Indeed, it is estimated that by 2010, one in every 250 adults in this country under the age of forty-five will be a survivor of a childhood cancer. Yet this success comes at a price, since for many young cancer patients, the treatment that saves their lives also destroys their fertility. This reality has given rise to oncofertility.

According to the American Society for Reproductive Medicine, the only current, nonexperimental treatment options for preserving fertility in cancer patients involve freezing and banking sperm or embryos. New possibilities are on the horizon, however, and I want to focus on one that involves a technique for retrieving and storing ovarian tissue. Here a concrete example may be of use. Suppose a woman diagnosed with breast cancer must begin treatment immediately, but is deeply committed to having children in the future and aware that her treatment may leave her infertile. Undergoing hormone stimulation in the hope of freezing mature eggs is not an option, since it will delay the start of her treatment and may in fact cause her cancer to proliferate.

Until now, such a woman faced a discouraging, lose-lose choice. But soon she may be able to benefit from ovarian tissue transplantation. This experimental procedure begins with laparoscopic surgery to remove ovarian tissue before the start of cancer treatment. The ovarian tissue, which contains immature egg follicles, is then frozen and banked for future use. Down the road—possibly decades down the road—our hypothetical patient, now cancer-free and hoping to have a child, can thaw the frozen tissue and try to conceive. At that point the challenge is to develop immature follicles, which cannot be fertilized, into mature eggs that can be. There are currently several experimental ways of attempting this, the most direct of which, known as orthotopic grafting or autotransplantation, transfers the ovarian tissue back into the woman’s body, near the site from which it was removed. If all goes well, the transplant will restore endocrine function, and after a time, ovulation of mature eggs will resume. To date, at least one live birth to a cancer survivor using this experimental treatment has been reported.

To consider orthotopic grafting in light of Catholic teaching, we need to turn to Donum vitae, the Vatican instruction on reproductive technology issued in 1987, and its recently published companion document, Dignitas personae. Between these two texts, the Vatican has addressed most of the major moral issues that have arisen in the wake of IVF. Freezing embryos, experimenting on them, selling gametes and gestational “services,” stem-cell research, cloning, preimplantation genetic diagnosis, turning procreation into a kind of manufacturing process—all have been taken up in these two documents.

According to Donum vitae, two fundamental values should govern moral reflection on assisted reproduction: “the life of the human being called into existence,” and “the special nature of the transmission of human life in marriage.” The first value, namely, the right to life of the embryo from conception, served to shape judgments about what could be done with human embryos, effectively prohibiting any form of assisted reproduction that fails to accord embryos complete moral respect as persons—such as in vitro fertilization, nontherapeutic embryo experimentation, freezing embryos, and gestating embryos in nonhuman hosts.

The second value, the special nature of the transmission of human life in marriage, relates to IVF’s ability to disembody procreation by facilitating reproduction through the manipulation of sperm and egg in a laboratory. The insistence that procreation be the result of a loving act of sexual intercourse resists reproductive medicine’s tendency to reduce the creation of human life to the mere manipulation of gametes. Both documents make clear that Catholic opposition to certain forms of assisted reproduction is not rooted in an antitechnological mindset, but rather in a concern that technology not dominate an area of human life rooted in love and a commitment to the welfare of children.

Since orthotopic ovarian-tissue transplantation does not involve creating embryos in the laboratory, and since, if the transplant is successful, procreation follows from marital intercourse, the procedure should be acceptable under current church teaching. Indeed, the technique seems profoundly consonant with the anthropology set out in Donum vitae. Quoting Pope John Paul II, the document reminds us that “‘each human person, in his absolutely unique singularity, is constituted not only by his spirit, but by his body as well. Thus, in the body and through the body, one touches the person himself in his concrete reality. To respect the dignity of man consequently amounts to safeguarding this identity of the man corpore et anima unus.’” I do not think it a stretch to say that helping a cancer survivor have children is partly an attempt to stitch back together a spiritual and bodily unity that cancer has sundered. Ovarian tissue transplantation and the return to reproductive function can profoundly touch the person whose sense of bodily integrity and spiritual wholeness has been deeply threatened.

Orthotopic tissue transplants are experimental, and at this point, even the option of storing ovarian tissue should be offered to patients only as part of an experimental protocol approved by an ethics committee. But if freezing ovarian tissue is offered as part of a research effort, I see no moral reason why a patient should not enroll in such a study. Similarly, if a woman has stored ovarian tissue, there seems to be nothing intrinsically wrong with participating in a research study that involves placing this tissue back in her body in the hope that she will conceive a child naturally. We will want to be as sure as we can be that conceiving a child after storing ovarian tissue does not result in significant risk of harm to the child. But conceiving a child in this fashion does not seem per se wrong, and Catholic tradition ought to embrace such a treatment when it is no longer experimental.

If Catholic teaching on reproductive technology provides a useful framework for thinking about a novel technology for restoring reproductive health, does this new technology also provide a lens for examining Catholic teaching? I think it does. Consider, for instance, the case of ovarian-tissue transplantation reported in the New England Journal of Medicine a few years ago. It involved identical twins, one of whom developed ovarian failure at age fourteen. When the twins were in their mid-twenties, the sister who remained fertile donated ovarian cortical tissue to her twin for surgical transplantation. After several months, the infertile twin began to ovulate again and went on to conceive a child with her husband.

This case points to the way new technology continually confounds our traditional categories of thought. The infertile twin produced a mature egg in vivo, conceived an embryo through intercourse with her husband, and sustained a pregnancy that resulted in the birth of a child—a child who, in the traditional language, was begotten, not made. Nevertheless, the original tissue containing the immature eggs came from another woman—namely, her sister. Of which sister is the child the offspring? The answer is complicated by the fact that the twins are identical, possibly making it difficult to determine which one is the genetic mother.

To appreciate the confounding nature of the case, consider one criterion set out in Dignitas personae for distinguishing licit reproductive interventions from illicit interventions. According to the Congregation for the Doctrine of the Faith, hormone treatments and various types of surgery are acceptable because they are “authentic.” “All these techniques,” the CDF writes, “may be considered authentic treatments because, once the problem causing the infertility has been resolved, the married couple is able to engage in conjugal acts resulting in procreation, without the physician’s action directly interfering in that act itself.” Given this criterion, ovarian tissue transplants, even ones where one woman is donating to another, are authentic.

Of course, Catholic teaching on assisted reproduction has also insisted that genetic and social parenthood not be separated. But what does genetic parenthood mean in the context of an ovarian tissue transplant between identical twins? And since ovarian tissue transplantation—like organ transplants—restores a complex biological system to normal function, should it be treated more like a kidney transplant than an egg donation?

I don’t know the answers to these questions, but I do know that these and many similar ones loom on the horizon. As progress in curing childhood cancer continues, efforts to preserve and restore the fertility of cancer survivors will steadily increase as well. Catholic teaching on assisted reproduction may be a helpful place to begin thinking about such efforts. But we should also acknowledge—and welcome—the possibility that new technologies in turn may lead us to rethink Catholic teaching. Striking the right balance will be the key: finding a way to respect embryonic life and resist reducing procreation to a mere manufacturing process, even as we embrace the potential of new medical technologies to make the broken human whole again.

Published in the 2009-02-13 issue: 
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